From the Guidelines
Haemobilia should be managed with angiographic embolization (AE) as the treatment of choice, especially in cases of ruptured intrahepatic pseudoaneurysm, to prevent further bleeding and improve patient outcomes. Haemobilia is a condition characterized by bleeding into the biliary tract, often resulting from an abnormal connection between blood vessels and bile ducts. The most common causes of haemobilia include trauma, iatrogenic causes, tumors, inflammatory conditions, and vascular abnormalities 1. Diagnosis involves a combination of clinical assessment, laboratory tests, and imaging studies such as CT angiography, MRCP, or ERCP.
Clinical Presentation and Diagnosis
Haemobilia typically presents with Quincke's triad: upper abdominal pain, jaundice, and gastrointestinal bleeding. Laboratory tests may show elevated liver enzymes and bilirubin, while imaging studies can help identify the source of bleeding. In patients with melena or hematemesis following liver trauma, bleeding from the ampulla of Vater (hemobilia) is highly suggestive of ruptured intrahepatic pseudoaneurysm 1.
Management and Treatment
Management of haemobilia depends on the severity of bleeding and underlying cause. For mild cases, conservative treatment with fluid resuscitation and blood transfusions may be sufficient. However, more severe cases require interventional radiology procedures like selective arterial embolization, which is the first-line treatment 1. AE is the treatment of choice for ruptured intrahepatic pseudoaneurysm, as it can effectively prevent further bleeding and improve patient outcomes. Endoscopic procedures like ERCP with stent placement may be needed to relieve biliary obstruction from blood clots. Surgery is reserved for cases where less invasive approaches fail.
Importance of Prompt Recognition and Treatment
Prompt recognition and treatment of haemobilia are essential, as severe cases can lead to life-threatening hemorrhage and biliary obstruction. Delayed treatment can result in increased morbidity and mortality, highlighting the need for timely and effective management. In the context of liver trauma, the guidelines recommend AE as the treatment of choice for hemobilia, especially in cases of ruptured intrahepatic pseudoaneurysm 1.
From the Research
Definition and Causes of Haemobilia
- Haemobilia refers to bleeding from and/or into the biliary tract, an uncommon but important cause of gastrointestinal hemorrhage 2, 3, 4.
- The majority of cases are iatrogenic, caused by invasive procedures involving the liver, pancreas, bile ducts, and/or the hepatopancreatobiliary vasculature, with trauma and malignancy being other leading causes 2, 5, 3, 4.
Clinical Presentation
- A classic triad of right upper quadrant pain, jaundice, and overt upper gastrointestinal bleeding (Quincke's triad) has been described, but is present in only 25-30% of patients with haemobilia 2, 3, 4.
- Jaundice, right-sided upper abdominal pain, and hematemesis are common symptoms 5.
Diagnosis
- Prompt diagnosis depends critically on having a high index of suspicion based on a patient's clinical presentation and history of recently undergoing hepatopancreatobiliary intervention or having other predisposing factors 2, 3, 4.
- Diagnosis can be confirmed by endoscopic retrograde cholangiopancreatography and angiography 5, as well as noninvasive imaging such as computed tomography 4.
Treatment
- Treatment depends on the severity and suspected source of haemobilia, ranging from supportive care to advanced endoscopic, interventional radiologic, or surgical intervention 2, 5, 3, 4.
- Angiographic occlusion is recommended as initial treatment to control haemobilia and render the patient stable for elective and definitive surgery 5.
- Therapeutic endoscopy is becoming a first-line approach in select cases, with interventional radiological and/or surgical intervention reserved for refractory or life-threatening cases 4.